"Held:
Respondents’ state causes of action fall
within ERISA§502(a)(1)(B), and are therefore completely
pre-empted by ERISA §502 and removable to federal court.
Pp. 4–20."

"We hold that
respondents’ causes of action, brought to
remedy only the denial of benefits under ERISA-regulated benefit
plans, fall within the scope of, and are completely pre-empted
by, ERISA §502(a)(1)(B), and thus removable to federal
district court. The judgment of the Court of Appeals is
reversed, and the cases are remanded for further proceedings
consistent with this opinion.7
It is so ordered."

If NASA Columbia tragedy can find some solutions
for preventions and resolutions, why can't health-care crisis with
potential of paralyzing nation's economy and security deserve and demand
some results oriented and compliant but practical solution?

"Three people were arrested
this morning for allegedly orchestrating a scheme to defraud
the customers of Employers Mutual LLC, a company that
purported to provide health care coverage to more than 20,000
people across the United States, but left more than $30
million in unpaid claims for medical services when it was shut
down."

"Deputy Attorney General
James B. Comey stated: “The Department of Justice is committed
to the prosecution of individuals who operate bogus health
insurance schemes. These schemes victimize the employees,
individuals and families who believed they had health care
coverage but are left uninsured with devastating personal
liability for unpaid medical claims.”

"One of the Department of
Labor's highest priorities is to protect the benefits of
workers and their families,” said Ann L. Combs, Assistant
Secretary of Labor for Employee Benefits Security. “These
corrupt individuals took advantage of the trust that small
businesses and their workers placed in them to provide
health benefits. Today's indictments demonstrate our
commitment to vigorously pursue those who prey on people
seeking affordable health coverage for themselves and their
families and ensure that they are prosecuted to the fullest
extent of the law."

"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"

"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."

It
is well known and understood that State Prompt Pay and clean claim
rules do not apply to governmental plans, military plans,
Medicare/Medicaid, worker's compensation, and liability/personal
injury claims as well as self-funded plans.

“The terms ''employee welfare benefit plan'' and ''welfare plan'' mean
any plan, fund, or program which was heretofore or is hereafter
established or maintained by an employer or by an employee organization,
or by both, to the extent that such plan, fund, or program was
established or is maintained for the purpose of providing for its
participants or their beneficiaries, through the purchase of insurance
or otherwise” (underline added)

It is also
important and necessary to understand that timely payment of the
ERISA claim, by self-insured and fully-insured ERISA plans, are
clearly "related to" ERISA benefits, and ERISA preemption will make
state law prompt pay and clean claim rules unenforceable, not only
against self-insured ERISA plans, but also against fully-insured
ERISA plans, which together makes state law Pay act useless for up
to 80% of health-care claims and more than 50% of health expenditure
in the United States.

Clearly and
undoubtedly, if a state law prompt pay provision is consistent with
ERISA claim regulation with respect to time frame summarized in the
table above and below, then it is not preempted, if inconsistent
with ERISA claim regulation time frame (some states require less
than 30 days for post-service claim initial determination and
payment), such state law prompt pay provision will be preempted.
Practically speaking, if ERISA, the federal law, provides primary
jurisdiction and time frame within which an initial determination
has to be made for both self-insured and fully-insured employee
health care benefits plan that is better than most state laws, why
don't
health care providers do something about the compliance of this
new federal claim regulation?

Excerpt: "The Hawaiian Supreme Court
ruled November 18, 2004, that a state law that gives
Hawaii's insurance commissioner authority to conduct
external reviews of health insurance plan decisions is
'impliedly' preempted by the Employee Retirement Income
Security Act (ERISA)."

Misconception and
Mystery Of ERISA Preemption and Savings Clause For State Insurance
Laws

1) It was very
confused and frustrated among state regulators and both sides of
advocates of state law protections as to whether ERISA preemption will
supersede and invalidate anything and everything in State laws in
regulating health insurance.

2) US Supreme
Court ruled that ERISA does not preempt Illinois External Medical Review
and Kentucky Any Willing Provider (AWP) provisions because these are the
state laws regulating insurance industry as a whole and affect insurance
risk pool, and they do not provide for any direct remedy from state law
to interfere with ERISA benefits civil enforcement, no impermissible
connections.

3) After these
Supreme Court rulings, the issue is not settled as to whether State
prompt pay act and rules are preempted by ERISA for fully-insured health
plans with purchase of health insurance through commercially licensed
insurers under state laws.

E."But this case addresses a
state regulatory scheme that provides no new
cause of action under state law and authorizes no new form of ultimate
relief. While independent review under §4-10 may well settle the
fate of a benefit claim under a particular contract, the state statute
does not enlarge the claim beyond the benefits available in any action
brought under §1132(a). And although the reviewer's determination would
presumably replace that of the HMO as to what is "medically necessary"
under this contract,9the relief ultimately available would still
be what ERISA authorizes in a suit for benefits under §1132(a).10
This case therefore does not involve the sort of additional claim or
remedy exemplified in Pilot Life, Russell, and
Ingersoll-Rand, but instead bears a resemblance to the
claims-procedure rule that we sustained in UNUM Life Ins. Co. of
America v. Ward,
526 U. S. 358 (1999), holding that a state law barring enforcement
of a policy's time limitation on submitting claims did not conflict with
§1132(a), even though the state "rule of decision," id., at
377, could mean the difference between success and failure for a
beneficiary. The procedure provided by §4-10
does not fall within Pilot Life's categorical preemption."
Rush Prudential Hmo, Inc. V. Moran

F."And
the results are clear. Today, 47 states have laws and/or regulations
requiring the timely payment of health insurance claims. The AMA has
worked with 30 states to pass laws specifically based on AMA model
legislation. The AMA model legislation requires MCOs and other payors to
pay claims within 14 days of
submission when filed electronically and within 30 days if submitted on
paper. Such entities are required to pay
interest on claims that are not paid within specified timeframes.
The AMA model legislation also provides physicians
a private right of action that allows
them to sue the MCO for noncompliance." AMA Late
Payment of Claims(pdf),American Medical Association Model
Managed Care Contract: Supplement 8.[Page 2]

3.Distinction between
state law prompt pay act with late pay penalties and
independent/external medical review statutes and regulations

B.Prompt Pay Regulations for timely
initial benefits determination are "pure eligibility decisions" as
fiduciary decisions under ERISA while "independent medical reviews" as
"mixed treatment and eligibility decisions" are not fiduciary decisions
under ERISA as United States Supreme Court unanimously ruled in PEGRAM et al. v. HERDRICH.
Any Willing Provider Regulations do not interfere with "pure eligibility
decisions" by a fiduciary under ERISA.

“A state law relates to an ERISA plan “if
it has a connection with or reference to such a plan.” Shaw v. Delta Air
Lines, Inc., 463 U.S. 85, 97. To determine whether there is a forbidden
connection, the Court looks both to ERISA’s objectives as a guide to the
scope of the state law that Congress understood would survive, as well
as to the nature of the state law’s effect on ERISA plans. California
Div. of Labor Standards Enforcement v. Dillingham Constr., N. A., Inc.,
519 U.S. 316, 325. Applying this framework, the state statute has an
impermissible connection with ERISA plans, as it binds plan
administrators to a particular choice of rules for determining
beneficiary status.”
Egelhoff v. Egelhoff

Provider's
litigations against MCO on the claims of breach of MCO contract with
providers have failed to make any difference for ERISA plan chronic
and persistent delay of reimbursement with deep managed-care
discount compromise.

All internal appeals shall be
completed within the time limits required by regulations issued by the
Department of Labor, even those internal appeals for
which ERISA is not applicable. [page 50]

"(4) Nothing contained in
this Section 7.11 is intended, or shall be
construed, to supersede, alter or limit the rights or remedies otherwise
available to any Person under § 502(a) of ERISA or to supersede in any
respect the claims procedures under § 503 of ERISA." [page 53]

E.Both Aetna and CIGNA have agreed to
settle the class-action lawsuits by 950,000 physicians and agreed to
process appeals in accordance with ERISA claim
regulations for both ERISA claims and non-ERISA claims, and to
establish external review boards for Billing and Coding Disputes,
Medical Necessity Disputes and Policy Coverage Disputes,
in compliance with state external review laws, however external reviews
will not be available until internal appeals/ERISA appeals are
completely exhausted.

I.State regulators aggressive
enforcement and imposing multimillion dollar penalties against health
insurers and MCO's have provided limited relief of late payment problems
for non-ERISA plans and backslash of litigations by health insurers
against state insurance regulators on jurisdictional challenges for
ERISA claim dispute and delays.

A.ERISA “prompt pay” is provided through
ERISA claim regulation, especially through newly effective ERISA claim
regulation in response to Patient's Bill Of Rights campaign, which
unfortunately died in Congress after seven years of unprecedented
legislation and litigation across the country.

H.The most payment delay (prompt pay
violation) is due to the delay of initial decisionmaking in processing
and approval the benefits instead of lack of fund by the plan to pay the
claimant and providers.

J If initial benefits determination
was made in a timely fashion as outlined in the regulation but no
payment was made due to no funds from the plan to pay, DOL will sue the
plan sponsor to enforce compliance:

"Columbus,
Ohio - The U.S.
Department of Labor has sued defunct General Clay Products Corporation,
of Columbus, Ohio, for abandoning the company’s retirement plan, and
also filed suit against
its president for failing to forward employee contributions to the
health plan. The
alleged violations resulted in the loss of health insurance coverage for
company workers."

A.
§ 2560.503-1 (m) (4) defines the term of
"adverse benefits determination" by including approval for
benefits and entitlement decisions AND actions to
"provide or make payments" based on
initial benefits determination, instead of determination only without
"provide or make payment"

§ 2560.503-1 (m) (4) The term ``adverse
benefit determination'' means any of the following: a denial,
reduction, or termination of, or a failure
to provide or make payment (in whole or in part) for, a benefit,
including any such denial, reduction, termination, or
failure to provide or make payment that is
based on a determination of a participant's or beneficiary's
eligibility to participate in a plan, and including, with respect to
group health plans, a denial, reduction, or termination of, or
a failure to provide or make payment (in
whole or in part) for, a benefit resulting from the
application of any utilization review,
as well as a failure to cover an item or service for which benefits are
otherwise provided because it is determined to be experimental or
investigational or not medically necessary or appropriate.

B.
§ 2560.503-1 (f) (4) provides the timing of notification of "the
plan's adverse benefits determination" (decisions to pay and actions to
pay) instead of initial determination only without actions to pay "based
on a determination" (decisions to pay only)

§ 2560.503-1 (f) (4) "Timing of
notification of benefit determination. (1) In general. Except
as provided in paragraphs (f)(2) and (f)(3) of this section, if a claim
is wholly or partially denied, the plan administrator shall notify the
claimant, in accordance with paragraph (g) of this section, ofthe plan's adverse benefit determination
within a reasonable period of time, but not later than 90 days
after receipt of the claim by the plan, unless the plan administrator
determines that special circumstances require an extension of time for
processing the claim. If the plan administrator determines that an
extension of time for processing is required, written notice of the
extension shall be furnished to the claimant prior to the termination of
the initial 90- day period. In no event shall such extension exceed a
period of 90 days from the end of such initial period. The extension
notice shall indicate the special circumstances requiring an extension
of time and the date by which the plan expects to render the benefit
determination."

C."Failure to provide or
make payment" that is "based
on a determination" under ERISA
§ 2560.503-1 (f) (4) constitutes "adverse
benefits determination" under ERISA
§ 2560.503-1 (m) (4), required timing of notification of initial
benefits determination with decisions to pay and actions to pay

D.Although DOL explains, in its
FAQ A-10, that the time frames in these rules does not govern the
time within which claims must be paid, it also states "failure
to provide services or benefit payments within reasonable periods of
time following plan approval, however, may present
fiduciary responsibility issues under Part 4
off Title I of ERISA", DOL advances this position in
DOL FAQ C-12, that if any payment is
less than 100% of the medical bills, the plan must treat its
decision as an adverse benefit determination,
even for denied claims determined within time frames required under
ERISA
§ 2560.503-1 (f) (4).

DOL FAQ A-10: Do the time frames in these rules govern the time
within which claims must be paid?

No. While the regulation
establishes time frames within which claims must be decided, the
regulation does not address the periods within which payments that have
been granted must be actually paid or services that have been approved
must be actually rendered. Failure to provide services or benefit
payments within reasonable periods of time following plan approval,
however, may present fiduciary responsibility issues under Part 4 of
title I of ERISA.

DOL FAQ C-12: If a claimant submits medical bills to a plan for
reimbursement or payment, and the plan, applying the plan’s limits on
co-payment, deductibles, etc., pays less
than 100% of the medical bills, must the plan treat its decision
as an adverse benefit determination?

Under the regulation, an
adverse benefit determination generally includes any denial, reduction,
or termination of, or a failure to provide or make payment (in whole or
in part) for, a benefit. In any instance where the plan pays less than
the total amount of expenses submitted with regard to a claim, while the
plan is paying out the benefits to which the claimant is entitled under
its terms, the claimant is nonetheless
receiving less than full reimbursement of the submitted expenses.
Therefore, in order to permit the claimant to challenge the plan’s
calculation of how much it is required to pay,
the decision is treated as an adverse
benefit determination under the regulation. Providing the
claimant with the required notification of adverse benefit determination
will give the claimant the information necessary to understand why the
plan has not paid the unpaid portion of the expenses and to decide
whether to challenge the denial, e.g., the failure to pay in full. This
approach permits claimants to challenge whether, for example, the plan
applied the wrong co-payment requirement or deductible amount.
The fact that the plan believes that a
claimant’s appeal will prove to be without merit does not mean that the
claimant is not entitled to the procedural protections of the rule.
This approach to informing claimants of their benefit
entitlements with respect to specific claims, further, is consistent
with current practice, in which Explanation of Benefits forms routinely
describe both payable and non-payable portions of claim-related
expenses.
See § 2560.503-1(m)(4).

E.Approval for benefits,
"Positive Benefits Determination," on initial determination and its
notification without actual payment within time frames in accordance
with
§ 2560.503-1(f)(4) automatically constitutes "Adverse Benefits
Determination" defined under
§ 2560.503-1 (m) (4) and explained under
DOL FAQ C-12.

ERISA mandate
notification of clean claim rejection, improper claim filing, in 24
hours for urgent care claims, 5 days for preservice claims, failure
to notify claimant on claims not clean will foreclose future excuses
of cleanness of claim, which state law usually provides no parallel
protections.

ERISA mandate 30
days limits for initial benefits determination regardless of claims
clean or not for post-service claim.

ERISA has clear
definition of time frame of the beginning of claim, starting at a
time a claim is filed in accordance with the reasonable procedure of
a plan for regardless of the claim "clean or not",
§ 2560.503-1(f)(4).

8.Prompt Pay in State Laws Is Based on a
weak and ambiguous definition of "clean claim", which provides insurers
and MCO an open-door escape from "late pay statutory penalty because no
payment will be due at all on the ground of no coverage and the medical
necessity denials or by unreasonably requesting for additional
information, once out of prompt pay provision jurisdiction and falling
under State Law Improper Claim Practice Act, most states do not provide
private right of action (right to sue a private citizen) and state law
penalties; while ERISA provides for a closed-door requirements of either
notifying the claimant of insufficient and "not clean claim" in 1 to 5
days or timely benefits determination for "not clean claim". To make it
simple, under state law, if an insurance company and MCO can challenge
and escape "clean claim" requirements by doing anything, such as
requesting for additional information, then there is no requirements
from state law for an insurance company and MCO to make timely initial
and final decisions for those "not clean claims", while ERISA claim
regulation mandates notification of “clean or dirty claim” in a timely
fashion and provides for very limited extension by pending additional
information, and mandatory initial benefits determination in a much
faster timeframe than State laws, 72 hours for urgent care, 15 days for
preservice claim and 30 days for postservice claim, more importantly
ERISA also provides for timely response to appeals/reviews, failure to
respond to appeals/reviews will provide the claimant with exhaustion of
administrative remedy and deferential judicial review standards in
federal court.

9.ERISA Provides
Preemptive Protections and Clean
Claim Rejection Protections before the State Laws Can Be Seen on the
"Radar Screens" of State Law Jurisdictions for Prompt Pay and Clean
Claim Through Urgent Care and Pre-service
Claim Provisions:

A.New ERISA Claim Regulation provides
more protections for not only prompt pay protection but also preemptive
claim protections before State Law Prompt Pay Recognized Claims Can Be
Made;

B.ERISA Defines a Claim Preemptively
While State Law Prompt Pay Defines a Claim in a post-service fashion;

C.
ERISA § 2560.503-1(e) defines "claim for benefits" as a claim filed
or request for a plan benefit, including any pre-service Claims and any
post-service Claim;

D.
ERISA § 2560.503-1(m)(2) defines "pre-service Claim" as "(2) The
term ``pre-service claim'' means any claim for a benefit under a group
health plan with respect to which the terms of the plan condition
receipt of the benefit, in whole or in part, on approval of the benefit
in advance of obtaining medical care."

F.A plain English explanation of
pre-service claim is that if any ERISA plan requires pre-certification
or prior authorization or anything completed by the claimant or
providers as a precondition or perquisites before service is provided
and coverage is considered, it is a pre-service claim under ERISA, even
without performing a proposed health care service, complete and submit
a claim form to the plan, that is required under the state law to
trigger prompt pay laws,

G.Entire managed-care concept is
established on pre-certification, prior authorization and utilization
review as well as provroposed health care service, complete and submit
a claim form to the plan, that is required under the state law to
trigger prompt pay laws,

G.Entire managed-care concept is
established on pre-certification, prior authorization and utilization
review as well as provider participation and network access limitation.
Absolute majority of managed-care plans require pre-authorization and
pre-certification for significant and expensive medical procedures,

H.According to the latest researchers
report in the January issue of the Annals of Emergency Medicine, Ann
Emerg Med 2002;39:24-30, out of 980 emergency department visits
involving 951 patients, all of which covered under managed-care
insurance, 89% of visits require prior-approval or pre-certification.

I.Under state law, a pre-service claim
denial from prior authorization or pre-certification process will most
likely prevent from or discourage the patients and the providers to
initiate medical services or filing claims at all because of no
coverage,

"(A) Is a communication by a claimant or an authorized
representative of a claimant that is received by a person or
organizational unit customarily responsible for handling benefit
matters; and (B) Is a communication that names a specific claimant; a
specific medical condition or symptom; and a specific treatment,
service, or product for which approval is requested."

"(1)(i) The claims procedures provide that, in the case of a
failure by a claimant or an authorized representative of a claimant to
follow the plan's procedures for filing a pre-service claim, within the
meaning of paragraph (m)(2) of this section, the claimant or
representative shall be notified of the failure and the proper
procedures to be followed in filing a claim for benefits. This
notification shall be provided to the claimant or authorized
representative, as appropriate, as soon as possible, but not later than
5 days (24 hours in the case of a failure to file a claim involving
urgent care) following the failure. Notification may be oral, unless
written notification is requested by the claimant or authorized
representative."

N.Most of state law prompt pay
provisions do not provide any protections unless a traditional claim
form is completed and submitted. If state law provides any protections
for emergency care, it is only for the the coverage of emergency
treatment instead of clear timeline of benefit determination, and the
usually this type of coverage verification is provided with a legal
disclaimer for coverage and pre-approval disqualification.

O.Traditionally under managed-care
environment, the plan will require prior authorization,
pre-certification, prior approval people services is provided through
the plan provisions and provider contract agreement, after denial and
disapproval of admission or treatment requests, most health-care
providers will not provide services with patient concerns of
impossibility of payment or even complete and submit insurance forms for
reimbursement. This will be legally categorized as policy exclusion
denials. According to
The updated Harvard & RAND study, funded by the U.S. Department of
Labor (DOL), published on June 18, 2003 through Health Affairs,
pre-service claim denial is at 42% high while providers do not even
consider
this type of denials as managed-care denials. Without a claim, the
managed-care health plans will reject any appeals because there was no
claims or denials to appeal. With or without appeals, this will clearly
escape from any state law prompt pay jurisdictions.

Q.ERISA provides preemptive protections
and clean claim rejection protections before the state laws can be seen
on the "radar screens" of state law jurisdictions for prompt pay and
clean claim .

10.Failure
to Timely Make Benefit Determination and Review Decisions By the Plan
Administrator Will Lose ERISA Shield Protections for the Plan:

A.
Failure to timely make benefit determination and review decisions by the
plan administrator will constitute “deemed denied” review/appeal and
“deemed exhaustion of administrative remedy” under
§ 2560.503-1(l),
(“a decision on the merits of the claim” = de
novo judicial review, instead of deferential judicial review)
that will forfeit or preclude the plan from “deferential review
standard” on judicial review in federal court,
the most important
part of “ERISA Shield” on ERISA land. Gilbertson v Allied
Signal Inc

Excerpt: “[3] The primary question before us, of first
impression in this circuit, is whether a plan administrator’s decision,
other-wise within the administrator’s discretion, can be accorded
judicial deference when the purported final, discretionary decision is
not made until after the claim is, according to both the terms of the
plan and Department of Labor (DOL) regulations, already automatically
deemed denied on review. We conclude that
where, according to plan and regulatory language, a claim is
“deemed . . . denied” on review after the
expiration of a given time period, there is no opportunity for the
exercise of discretion and the denial is usually
to be reviewed de novo. While deference may be due to a
plan administrator that is engaged in a good faith attempt to comply
with its deadlines when they lapse, this is not such a case.”

D.In the following latest 2004 case
ruled under new ERISA claim regulation, a failure to render a timely
decision by the plan administrator resulted in "deemed denial", "deemed
exhaustion of remedy" and "loss of deferential review standard", the
worst for the plan in ERISA litigation. (Please note this is a pension
claim)

Excerpt: “......Linder argues, however, that under the
Department of Labor regulations in effect since January 1, 2002,
administrative remedies are deemed to be exhausted if the Plan
Administrator fails to respond to a claim for benefits within 90 days.
He argues that the Plan's claims procedures, which provide that a
claimant may administratively appeal if the Plan Administrator fails to
respond within 90 days, are invalid, as they fail to comply with ERISA's
procedural requirements. The Court agrees.

Under the express terms
of the regulations, Linder's claim is deemed exhausted, and he is
entitled to bring suit in federal court. See 29 C.F.R. § 2560.503-1(l).

......The ERISA
regulations are clear that claimants are "deemed to have exhausted
administrative remedies" in such circumstances. As 28 C.F.R. §
2560.503-1(l) provides:

In the case of the
failure of a plan to establish or follow claims procedures consistent
with the requirements of this section, a claimant shall be deemed to
have exhausted the administrative remedies available under the plan and
shall be entitled to pursue any available remedies under section 502(a)
of the Act on the basis that the plan has failed to provide a reasonable
claims procedure that would yield a decision on the merits of the
claim.......

IV. Conclusion
For the foregoing reasons, defendant's motion for summary judgment is
DENIED."

"Chicago, Illinois - A federal district
court in Indiana has ordered TRG Marketing, LLC of Indianapolis,
Indiana, and its executives to restore losses to the firm’s health
plan, pay unpaid health claims owed to plan participants nationwide,
and be permanently barred from serving as plan fiduciaries,
according to a judgment obtained by the U.S. Department of Labor.
The judgment resulted from a lawsuit in which the department alleged
that TRG executives diverted up to $3.4 million in health plan
assets to pay personal expenses for themselves and family
members.......

Under the judgment, TRG, William Paul Crouse and
Carmelo Zanfei were removed from their positions with the TRG health
plan and are permanently barred from service in the future to any
plan governed by the Employee Retirement
Income Security Act (ERISA). The
court found that the defendants engaged in self-dealing when they
used health premiums collected from employers to pay for commissions
to TRG’s enrollment brokers, trips overseas, expensive glassware,
personal expenses, charitable contributions, and a corporate line of
credit. A trial will be held to determine the amount to be repaid by
the defendants...."

"The
U.S. Department of Labor has sued the owner of a local business for
allegedly mishandling the funds withheld by employees for their
retirement plans, according to the complaint filed by Secretary of
Labor Elaine Chao and Susan Willer of the department's Kansas City,
Mo., office.....

He did not transfer the money to the 401(k) in
a reasonable time, did not determine the retirement plan's assets,
did not assert control over the assets or ensure that the assets
would be protected from losses, according to the complaint."

"Columbus,
Ohio - The U.S.
Department of Labor has sued defunct General Clay Products Corporation,
of Columbus, Ohio, for abandoning the company’s retirement plan, and
also filed suit against
its president for failing to forward employee contributions to the
health plan. The
alleged violations resulted in the loss of health insurance coverage for
company workers."

"Boston, Massachusetts - Volonte Care, Inc.
of Foxboro, Massachusetts, and company president Robert Michael Whitty
have agreed to pay $35,500 in outstanding medical bills for former
employees of the now-defunct nursing home and home healthcare company
to settle a lawsuit filed by the U.S. Department of Labor......

“The law clearly requires
those who administer employee benefit plans to do so in a careful,
prudent and honest manner solely for the benefit of participants,”
Benages said. “ A situation like this where promised benefits are
never paid while employee contributions continue to be collected is
totally unacceptable”

6.Request for Prompt Payment under ERISA,
and File "Prompt Appeals" in Accordance with ERISA Claim Regulation
Instead of State Prompt Pay Laws

7.Appeal Only To "Named Fiduciary"
Identified by SPD (Summer Plan Description, ERISA Version of Insurance
Policy) to Timely and Promptly Trigger the Appeal Process, after
Untimely and Failure in Timely Initial Claim Determination

8.Prompt and Timely Finishing At Least
Two Level Appeals To Exhaust Internal/Administrative Remedies, to
Foreclose Any Future Excuses in Claim Delays in
Federal Court

9.Make a Final Demand for Payment As
Volunteer Appeal under ERISA and Notification of Lawsuit in Federal
Court As Provided by ERISA

10.Prompt and Maximal Reimbursement from
ERISA Plans Will Be More Secured When ERISA Shield Is Destroyed and No
Winning Chance to Defend a Delay in
Federal Court.

Forbes.com:"Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion of revenue because patients couldn't pay their
bills."

The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages $3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."

"According to the video, when faced with claims for identical
medical problems, Aetna separates the claims where no damages
are available - those subject to the federal Employee Retirement
Income Security Act, or ERISA - from non-ERISA claims, where
consumers can sue.1 2"

"Although Dr. Murphy is not engaged in the
traditional practice of medicine, to the extent that he renders
medical decisions his conduct is reviewable by BOMEX. Here, Dr.
Murphy evaluated information provided by both the patient's
primary physician and her surgeon. He disagreed with their
decision that gallbladder surgery would alleviate her ongoing
symptoms. S.B.'s doctors diagnosed a medical condition and
proposed a non-experimental course of treatment. Dr. Murphy
substituted his medical judgment for theirs and determined that
the surgery was "not medically necessary." There is no other way
to characterize Dr. Murphy's decision: it was a "medical"
decision."

"We affirm the trial court's ruling that BOMEX
has jurisdiction to review medical decisions which could affect
the health or safety of a patient or the public, including
decisions Dr. Murphy renders as medical director for Blue Cross.
...."

Recent Federal Court Ruling in a Case with
$10,600 medical claim, insurance Co. refused to pay, provider
made numerous demand for payment in almost one year, but no
appeals filed, the court dismissed the lawsuit because provider
failed to exhaust administrative remedy, as required under ERISA,
by filing ERISAclaim appeals. This situation is so popular
in health-care community.

Health-care provider alleged medical claims
submitted to Aetna for reimbursement, Aetna asserted no receipt
of medical claims, no written denials. Health-care
provider failed to present proof of claim submission, claim
denial and ERISA claim appeals. This case was dismissed. ERISA
health-care claims are handled in federal court, state law is
generally not applicable.

Excerpt: "Georgia has fined
Humana Employers Health Care of Georgia Inc. $400,000 for
violating the state's prompt pay law, the second time in as many
years that the HMO has been fined for dragging its feet on
paying claims." (insure.com)